User Guide — Electronic Eligibility Verification

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This page provides an overview of electronic eligibility checking.

 

athenahealth maintains electronic eligibility linkages to many payers and automatically checks a patient's status 3 days before a scheduled appointment. You can also check eligibility on demand at any time, if the patient has coverage from a payer with which we have a connection. You are responsible for examining the results of eligibility checks and resolving any ambiguous results. If a patient has coverage from a payer with which athenahealth does not have electronic eligibility verification, you are responsible for contacting the payer to determine whether coverage is in force prior to an appointment.

Note: Electronic eligibility check results reflect payer data at the time of the electronic query. The results do not take into account the date of service of the appointment.

 

See also: Eligibility Verification — List of Payers.

 

Claims denied for eligibility related reasons (for example, service not covered, wrong insurer, patient demographic issues) take 20 to 50 days longer to pay than "clean" claims, so eligibility checking is critical to your cash flow.

 

 

athenaOne runs a nightly utility program that checks for eligibility before a patient's scheduled appointment. The default time frame for this automatic eligibility checking is 3 calendar days prior to an appointment. To set the number of days to a value from 1 to 5, contact the CSC by selecting Support > Create Case or Call in the Main Menu.

 

In addition to the nightly check, appointments scheduled to occur within the 3-day window are included in our hourly eligibility check utility. This utility ensures that short-notice appointments have eligibility verification as well.

 

The results of this automatic checking are reflected on the following pages:

 

The eligibility check gives office staff time to contact scheduled patients and correct potential problems with coverage before patients arrive for their appointments.

 

athenaOne performs automatic (or "quiet") eligibility checks whenever a claim is created and when:

  • Electronic eligibility is available for the package of the policy
  • A valid eligibility check has not been performed in the last 5 business days
  • The status of the patient's insurance has not been manually set in the last 5 business days
  • The Member ID/certification number is changed
  • You create an appointment using the Create Walk-In Appointment option on the Patient Actions Bar; from the Schedule Appointment page (for the current date or the next day); or from an interface

Note: In their 270/271 companion guides, payers list their acceptable combination of patient demographic search criteria in outgoing 270 transactions. athenahealth always sends these industry-standard patient demographics: first name, last name, gender, date of birth, and member ID.

 

 

 

 

A provider must be "enrolled" with the payer or clearinghouse for electronic eligibility verification. Enrollment is accomplished by a dedicated athenahealth team.

 

Enrollment refers to an agreement between a clearinghouse (or payer) and a provider that says that athenahealth, on behalf of the provider, can send requests and receive information about his/her patients' eligibility for coverage via athenaOne, and that athenahealth, on behalf of the provider, provides connectivity (via athenaOne) with the clearinghouse or payer for all the various payers where the provider is credentialed. See also: Enrollment Services

 

Successful electronic eligibility verification via athenaOne also requires the following:

  • Patients must have insurance from an active payer (see list of payers).
  • Required eligibility search criteria must be in athenaOne (criteria vary by payer).
  • Usual or scheduled provider must be enrolled for electronic eligibility with the clearinghouse or payer.
    • If the scheduled provider does not have a valid eligibility enrollment status with the payer, we verify the usual provider.
    • If there is no upcoming appointment, the usual provider must be selected from the usual provider menu and enrolled.

 

 

 

You can perform a manual electronic eligibility check from athenaOne from several places:

 

 

 

Electronic eligibility check results reflect payer data at the time of the electronic query. The results do not take into account the date of service of the appointment.

Note: If the enrollment status for the provider is set to any status other than COMPLETE, the eligibility transaction is not sent and the following error is returned when eligibility is automatically or manually checked: "This provider is not enrolled for electronic eligibility checking."

 

The athenaOne system formats and displays whatever information we receive from the payer. If the payer's electronic eligibility file contains formatting or data errors, these anomalies also appear on the Payer-Provided Eligibility Details page.

 

Note: Most payers use the ANSI standard for eligibility transactions; athenaOne provides expanded benefit information whenever the payer sends the ANSI standard transaction.

 

athenahealth has a dedicated team that works to establish electronic eligibility checking for as many payers as possible. However, athenahealth can provide electronic eligibility checking only for payers that are willing and able to make this information available to us electronically.

 

After we establish electronic eligibility checking for a payer, it is important to understand that:

  • athenahealth has no control over the availability of the payer's electronic eligibility system.
  • athenahealth has no control over the accuracy of the electronic eligibility information that the payer transmits.

In other words, the availability and accuracy of our electronic eligibility checking depends on the availability and accuracy of each payer's system. athenahealth actively tracks payer status and helps payers improve the availability and accuracy of the information they do provide.

 

In spite of our best efforts to increase our payer coverage and the reliability of this information, a payer may deny a claim even when athenaOne receives a "Member is eligible" response from the payer.

  • "Member is eligible" indicates that the patient is on file at the payer with active coverage, but it does not guarantee that a given claim will be paid.
  • Benefit coverage depends on the type of service, provider network status, and patient classification on the policy.
  • Eligibility information must be applied correctly to a patient encounter to effectively prevent a denial.

Refer to Eligibility Verification to view the current list of payers that have electronic eligibility checking enabled with athenahealth.

 

The results of the most recent eligibility check information appear on the patient's Quickview page to indicate whether a patient is insured for the date of service; copayment information or restrictions are also usually supplied in the eligibility message.

 

When a patient's eligibility is checked electronically, these fields on the Add /Update Policy Details page are updated: Eligible status, Last inquiry, and Last eligibility message.

 

From the Workflow Dashboard, you can click a linked number in the Eligibility column to access the Eligibility Worklist for that department (in the Task Bar). The worklist provides appointment date, patient name, and a link to the patient's Quickview page for each patient on the list.

 

The Eligibility and Phone page also provides you with information about patient eligibility (On the Main Menu, click Calendar. Under APPOINTMENTS, click Eligibility and Phone List).

 

 

BCBS routing is the process that athenahealth uses to store a patient's home plan while still processing claims using the doctor's local BCBS carrier.

 

The Blue Cross and Blue Shield Association has a network called the Blue Exchange. Our BCBS eligibility handling is compatible with the Blue Exchange, so we can check eligibility successfully for patients covered by out-of-state BCBS payers.

 

Any eligibility transaction that is sent through the Blue Exchange is routed to the correct BCBS carrier (as long as they participate in the Blue Exchange) based on the alphabetic prefix in the patient's ID number. Correct routing of the transactions is based on the assumption that the transaction is sent to the provider's local BCBS carrier. This allows the local BCBS to validate the provider's credentials before requesting patient coverage information from another BCBS.

 

 

 

A patient's Medicare suffix can change from time to time due to a change in circumstances. For example, when a patient who was previously covered under a spouse's policy reaches age 65 and receives his/her own policy, the patient's suffix changes as well. This change can happen without the patient's knowledge. If this occurs, an old Medicare member ID image may still be on file with your practice.

 

When an eligibility request is sent to Medicare, the response shows the most recent member ID that Medicare has on file for the patient. If the old member ID is sent in the eligibility transaction, an "Unverified" eligibility status is returned.

 

To address this issue, athenaOne will resend these unverified responses with the new member ID and fetch an eligible response from the payer; athenaOne then update the patient's policy with the updated member ID automatically. The updated member ID is the one that should be used to bill the claim.

Note: There is a short time lapse in which an unverified response will be seen before the new eligibility check is automatically sent.

 

 

 

 

 

On the Workflow Dashboard, the Eligibility column indicates, by department, the number of patients with upcoming appointments that may be ineligible for coverage under their current policy. You can click the linked numbers to access the Eligibility Worklist for that department. The worklist provides appointment date, patient name, and a link to the Quickview page for each patient on the list.

 

 

 

The Eligibility and Phone page provides you with information about patient eligibility. The Unverified eligibility status is displayed in bold red if the eligibility status is not Eligible.

 

 

 

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